MPR 1

The local health department (LHD) Children’s Special Health Care Services (CSHCS) program shall assure that adequate, trained personnel are available to provide outreach, enrollment and support services for children and youth with special health care needs (CYSHCN) and their families.

Reference: CSHCS Guidance Manual for Local Health Departments, Standard of Practice.

Indicator 1.1

LHD CSHCS shall maintain a staffing configuration that includes a Registered Nurse and a program representativeto provide program services to CSHCS client caseload and meet program requirements. When changes occur, the LHD shall submit a CSHCS staff roster to the Michigan Department of Health & Human Services (MDHHS) CSHCS program and shall notify the MDHHS within 30 days when changes to the roster occur.

This indicator may be met by:

There shall be evidence that the staffing is adequate to provide the required program services to the community and caseload. The table below provides recommended staffing levels based on caseload. It is incumbent on each LHD to determine the appropriate staffing levels/configuration to meet the needs of the community and of the CSHCS enrolled caseload.

Caseload Ranges / Recommended Registered Nurse FTE / Recommended Program Representative FTE
<150 / .25 / .25
150-400 / .50 / .25-.50
401-600 / 1.0 / .50
601-800 / 1.0-1.5 / 1.0
801-1,300 / 2.0 / 1.0-1.5
1,301-2,000 / 2.0-2.5 / 1.5-2.0
2,001-2,800 / 3.0 / 2.0
2,801-3,300 / 5.0 / 5.0
>3,300 / 6.0 / 6.0

There shall be evidence of a current, accurate staff roster. If changes have been made to the staffing, documentation exists showing that the revised roster was sent to MDHHS within the 30 day time frame.

Documentation Required:

All below are required.

  • Roster indicating the LHD CSHCS staffing configuration. The roster should match the reported and observable staffing.Materials should be submitted in advance of the review.
  • On-site interview describing how the LHD CSHCS staffing configuration adequately meets the needs of the community (outreach/case-finding) and of the CSHCS enrolled caseload.

If changes to the staffing roster occur the following are also required:

  • Dated correspondence (electronic or written) that the staff roster was submitted to MDHHS initially and within required time frame following changes to staffing. Materials should be submitted in advance of the review.
  • Personnel records indicating when staffing changes occurred as compared to submission of roster to MDHHS.

Evaluation Questions:

  • Does the LHD staffing configuration allow the LHD to provide quality, CSHCS-required services?
  • Is the LHD CSHCS Program maintaining an accurate CSHCS staff roster and communicating changes in staffing to MDHHS in a timely manner?

Indicator 1.2

New LHD CSHCS employees shall take required courses, as listed in the Guidance Manual, within 90 days of employment. All LHD CSHCS staff shall take these courses within 90 days of notification that the training courses have been updated. At least one person from each health department’s CSHCS program shall participate in CSHCS state-office regional meetings.

This indicator may be met by:

There shall be evidence that exists of timely staff training using required courses within the specified timeframes.

There shall be evidence of routine staff training/updating through participation in the CSHCS sponsored regional LHD meetings by at least one person from each health department.

Documentation Required:

All below are required.

  • Written policy and procedure delineating staff training of new and on-going employees.
  • Printed certificate of completed required training courses including name and date. Materials should be submitted in advance of the review.
  • Dated notation in the employee’s personnel record by the supervisor that the other required courses have been taken when no printable certificate available for the training exists. Materials should be submitted in advance of the review.
  • Staff roster with county assignment as compared to the CSHCS regional meeting sign-in sheet showing registrants and attendees (signature of attendees). If attendee neglected to sign in, other evidence of attendance as possessed by attendee/LHD.

Evaluation Questions:

  • Are LHD CSHCS program staff oriented timely and then updated as needed to the CSHCS program through use of required courses, as listed in the Guidance Manual?
  • Did at least one CSHCS staff person from each health department attend MDHHS sponsored CSHCS regional meetings?

MPR 2

In accordance with the security and privacy provisions of the Health Insurance Portability and Accountability Act (HIPAA), the local health department CSHCS program shall manage CSHCS client protected health information (PHI) in a secure and private manner that results in coordinated care.

Reference:HIPAA, CSHCS Guidance Manual for Local Health Departments, Standard of Practice.

Indicator 2.1

The LHD CSHCS program staff shall routinely use the CSHCS On-Line database to securely manage CSHCS client PHI and effectively and efficiently coordinate care.

This indicator may be met by:

There shall be evidence of proficient and regular use of the CSHCS On-Line database by all LHD CSHCS program staff to successfully carry out local CSHCS functions.

Documentation Required:

All below are required.

  • Written policy and procedure delineating use of the CSHCS On-Line database to carry out daily functions.
  • During onsite reviews LHD staff will be asked to demonstrate proficiency with the database by showing reviewers how to find one or more of the following pieces of information using the CSHCS On-Line database:
  • Client look-up
  • Medical report received date
  • Medical report approved date
  • Listing of approved providers
  • Renewal information
  • Where to find MDHHS/CSHCS notes
  • Client eligibility begin/end dates
  • How to print county-specific reports

Evaluation Questions:

  • Are the LHD staff using the CSHCS On-Line database regularly and accurately to efficiently, effectively and securely obtain the information necessary to carry-out their daily functions such as communicating with CSHCS-enrolled clients and/or their families and coordinating CSHCS client care?
  • Are policy and procedures in place that include use of the CSHCS On-Line database?

Indicator 2.2

The LHD CSHCS program staff shall use the secure electronic method of communication for sharing of PHI designated by CSHCS (e.g. EZ-Link).

This indicator may be met by:

There shall be evidence of proficient and regular use of the designated electronic system for sharing PHI, by the appropriate LHD CSHCS program staff to successfully carry out CSHCS functions.

Documentation Required:

All below are required.

  • Written policy and procedure delineating use of the designated electronic data system for secure sharing of CSHCS PHI to carry out daily functions.
  • Evidence of use of this data system (system “footprints” of use).

Evaluation Questions:

  • Are the LHD staff regularly and accurately using the designated electronic system for sharing PHI to efficiently, effectively and securely share the information necessary to carry-out their daily functions including communicating with MDHHS and coordinating CSHCS client care?
  • Are policy and procedures in place that includes use of the designated electronic data system for sharing PHI?

Indicator 2.3

LHD CSHCS shall have a shared, comprehensive client record for CSHCS enrollees that reflects communication among the staff and includes dates and staff identifier.

This indicator may be met by:

There shall be evidence that the LHD maintains comprehensive client record on all CSHCS enrollees that all local CSHCS staff use to record contacts and document services provided.

Documentation Required:

All below are required.

  • Physical evidence of comprehensive client records exists. The previous threeyears’ activities in client charts should be submitted in advance of the review (individual clients will be specified by MDHHS).
  • Evidence that all CSHCS staff record contacts/CSHCS services in one client record including date of interaction and staff identifier.
  • Evidence of referrals within the program (CSHCS program representative referring to CSHCS nurse and vice versa).

Evaluation Questions:

  • Does the LHD CSHCS program maintain shared client records (all staff document in one, comprehensive client record)?
  • Do the chart notations indicate communication among the CSHCS staff to ensure coordination of care for the CSHCS client?
  • Do all client record notations include a date and staff identifier?

Indicator 2.4

LHD CSHCS shall only access the minimum information necessary in the CSHCS On-Line database or other electronic data systems to complete tasks for CSHCS clients.

This indicator may be met by:

There shall be evidence that LHD CSHCS staff implement the privacy provisions of HIPAA in carrying out their CSHCS tasks using the CSHCS electronic data systems and that staff receive the local health department’s policy and procedure regarding HIPAA compliance.

Documentation Required:

All below are required.

  • Evidence that HIPAA compliant LHD policy and procedures have been shared with LHD CSHCS staff.
  • Written policy and procedure delineating HIPAA compliant use of the CSHCS On-Line database.
  • The LHD maintains on file a copy of signed and dated HIPAA Agreement to Comply for each employee. Materials should be submitted in advance of the review.
  • On-site interview of how LHD CSHCS staff uses the data systems in a HIPAA compliant manner.

Evaluation Questions:

  • Have the LHD CSHCS staff received the LHD policy and procedure regarding HIPAA compliance?
  • Have the LHD CSHCS staff been informed of HIPAA rules regarding privacy and have they signed an agreement to comply with these rules?

Indicator 2.5

LHD CSHCS shall offer families a private location for the exchange of confidential information.

This indicator may be met by:

There shall be evidence that the LHD CSHCS program has a private location and it is offered to CSHCS families where they can privately exchange confidential information.

Documentation Required:

All below are required.

  • Written policy and procedure delineating how families are offered a private location to share confidential information with the LHD CSHCS staff.
  • Physical evidence of a private location.
  • On-site interview of how/when LHD CSHCS staff offer CSHCS clients and/or families the opportunity to discuss confidential information in a private location.

Evaluation Question:

Does the LHD CSHCS program have a private location for discussion of confidential information with CSHCS clients and/or families and is it routinely offered to them?

MPR 3

The local health department CSHCS program shall have family-centered policies, procedures and reporting in place.

Reference: (CSHCS Guidance Manual for Local Health Departments, Michigan Department of Community Health Mediciad Provider Manual, Standard of Practice, Health Resources and Services Administration (HRSA)/Maternal and Child Health Bureau (MCHB), Sec. 501 of Title V of the Social Security Act, MCHB Performance Indicator).

Indicator 3.1

LHD CSHCS shall regularly use the most current Children’s Special Health Care Services Guidance Manual for Local Health Departments (Guidance Manual) and the Medicaid Provider Manual to effectively and consistently carry out local program expectations, policies, and requirements.

This indicator may be met by:

There shall be evidence that the LHD CSHCS program staff routinely use the CSHCS Guidance Manual and Medicaid Provider Manual in carrying out local program expectations, policies, and requirements.

Documentation Required:

All below are required.

  • Written policy and procedure delineating how the LHD uses the most current Guidance Manual and Medicaid Provider Manual.
  • On site interview will include having all LHD CSHCS staff demonstrate their proficiency with the Guidance Manual and Medicaid Provider Manual by showing reviewer(s) how to find one or more pieces of information in the Guidance Manual and Medicaid Provider Manual as indicated by the reviewer(s).

Evaluation Question:

Has the local health department demonstrated compliance and competence in routinely using the current CSHCS Guidance Manual and Medicaid Provider Manual?

Indicator 3.2

LHD CSHCS shall have written policies and procedures in accordance with CSHCS published policy that are reviewed annually and updated as needed regarding local CSHCS program functions.

This indicator may be met by:

There shall be evidence of written policies and procedures (electronic or hard-copy) that stipulate local procedures in accordance with current CSHCS published policy. There shall be evidence that the written policies and procedures are reviewed annually and updated as necessary. See Addendum 1 for a complete list of policies.

Documentation Required:

All below are required.

  • Written policies and procedures with dated notation of annual review and revisions as necessary. Materials should be submitted in advance of the review.

Evaluation Question:

  • Does the local health department have written policies and procedures of local functions that are reviewed annually and updated as necessary?

Indicator 3.3

LHD CSHCS shall facilitate family input regarding the local CSHCS program at least annually.

This indicator may be met by:

There shall be evidence of outreach for family involvement for input, feedback, and recommendations regarding possible improvements to the overall local CSHCS program.

Documentation Required:

(The first bullet is required as written. Other documentation is needed to complete the requirement.)

  • Written policy and procedure delineating how and when family input is obtained.

Example of further documentation needed that meet the requirement, including but not limited to.

  • Copies of outreach to families e.g., family survey documents and results, satisfaction surveys, focus groups, meeting notes etc. Materials should be submitted in advance of the review.
  • On-site interview that indicates how family input is obtained and the outcome of family input.

Evaluation Questions:

  • Has the local health department elicited input from local families regarding the operation of the CSHCS program at the local level and how it could be improved?
  • How was the input utilized and/or incorporated to enhance the program?

Indicator 3.4

LHD CSHCS shall inform families of their rights and responsibilities in the CSHCS program and must include at a minimum the information contained in the CSHCS model found in the Guidance Manual.

This indicator may be met by:

There shall be evidence that families have been informed of their rights and responsibilities regarding the CSHCS program.

Documentation Required:

(The first bullet is required as written. Other documentation is needed to complete the requirement.)

  • Written policy and procedure delineating the CSHCS rights and responsibilities and how clients/families are informed of their rights and responsibilities and when.

Example of further documentation needed that meet the requirement, including but not limited to.

  • Dated client chart notation that rights and responsibilities were shared with the family and staff identifier.
  • Copy of written document given to families.
  • Evidence of it being posted.
  • On-site interview that indicates how families are informed of their rights and responsibilities.

Evaluation Questions:

  • Does the LHD CSHCS program inform clients/families of their rights and responsibilities regarding the CSHCS program?
  • Do the rights and responsibilities include the required minimum elements as found in the Guidance Manual?

Indicator 3.5

The local health department CSHCS program shall meet the Comprehensive Planning, Budgeting, and Contracting agreement (CPBC)reporting requirements annually.

This indicator may be met by:

There is evidence that the CSHCS LHD program submitted contract deliverables in accordance with the CPBC requirements for the previous three years .

Documentation Required:

All below are required.

  • Written policy and procedure delineating how the data, required for the CPBC agreement, is collected, compiled and submitted within the specified timeframe.
  • MDHHS receipt of data report within the required timeframe and including the required elements.

Evaluation Question:

Does the LHD CSHCS program submit the data report as required within the specified time?

MPR 4

The local health department CSHCS program shall collaborate with community partners and provide outreach, case-finding, program representation, and referral services to CYSHCN/families in a family-centered manner.

Reference: MCHB Performance Measures, Michigan Public Health Code, 333.5805 (1) a.

Indicator 4.1

LHD CSHCS shall routinely conduct outreach/case finding and program representation which includes, but is not limited to, the provision of information regarding CSHCS policy on diagnostic referrals, program eligibility, and covered services, to families, local hospitals, providers, the community and other agencies.

This indicator may be met by:

There shall be evidence of outreach, case-finding and program representation to families and community organizations.

Documentation Required:

(The first two bullets are required as written. Other documentation is needed to complete the requirement.)

  • Written policy and procedure delineating how outreach to families and the community is conducted.
  • Written policy and procedure delineating how outreach materials are disseminated to families and the community.

Example of further documentation needed that meet the requirement, including but not limited to.

  • Agendas for meetings held with hospitals or other community agencies. Materials should be submitted in advance of the review.
  • Sign-in sheets including title of meeting, location and date. Materials should be submitted in advance of the review.
  • Copies of letter inviting/confirming attendance at community functions or meetings. Materials should be submitted in advance of the review.
  • Log sheet summarizing outreach efforts. Materials should be submitted in advance of the review.
  • On-site interview that indicates how outreach, case-finding and program representation to families and community organizations are accomplished. Materials should be submitted in advance of the review.

Evaluation Question: